presentation

June 2 – 3, 2014
Dr. Phil Shin
Chief of Medicine and
Medical Director, Critical Care
&
Susan Woollard
Program Director, Medicine, Critical Care and
Elder Care
Improving Patient Flow
North York General
•
•
•
Community teaching hospital
Affiliated with the University of Toronto
Catchment area: 400,000 residents
Three Sites:
• General
• Branson
• Seniors’ Health Center
Beds:
• 413 acute care
• 200 long-term care
Volume:
• 110,000 Emergency Department visits annually
• 28,000 inpatient cases per year
• 5,800 births per year
Our Improvement Story
%
Conservable
Days
% of Time
EAA 15 or
Fewer
 25%
 89%
90th ED LOS –
Admitted
Patients
 43%
2012 – 2015 Strategy
2nd Out of 74 Ontario Hospitals in ED Performance Funding Rank
Access to Care
Governance
Structure
Escalation
Protected
Protocol for
Surgery when
cannot place
Meeting Time
Standards
Portering
Recommends
Medical
Office of
Operations
Access to Care Executive Sponsor
(George
&
UofT)
Advisory
Strategy
Improve
Committee
Karyn Popovich & Dr. Donna McRitchie
Roles & Branson CT
Cardiac
Clinic Need IPAC
Committee
Management
Family
Research
&
Inappropriate
Escalation
Expectations inService
Education SI Outreach
Care
Bed
Transfer
for
Medicine
Innovation
MH
and
Yellow
Escalation
Admissions to
Protocol
D/C Planning
Investigate
why
Consolidation
Environments
Improving
Long
ZonePatient
Process
Protocol PhaseWorkflow
Hospitalist
ALC Expedite
BDC
Wait Time
ALC is increasing
Access to Care Committee
Conservable Waits
Staffing: Problem
Review
3
Chair:
Karyn
Popovich
Site Visits to
ImprovementImprovements
Physician Service
Need
a
Cerner
Days
Working
when going
Admin
Janice
Lepper
Service
Southlake and
Expectations ED
Connecting
Flag for DI Group
overcapacity
Excellence
P&FCC
Do a Powerchart
Value TEG. More
Renovations
Care
Consent
PowerScribe
Model
Enhancements
Isolation
Improve Room
UltraAccess to Care Core Team
Stream
Analysisbenchmarking
Medical Imaging
Upgrade
to
A2C
Change
D/C
Planning
Capacity
Sound
TATsMaria Muia and Mary Lynne MacMaster
on UMS
/ BMS
SI Leads:
Patient
Flow
Engagement
Management
Service Delivery
PS360
Sustainability
Project Manager:
James
Ibbott
Improvement
eCare Consultants
Utilize
NPs
in
ED
Groups
Navigators
Quality &
Admin Jeanette Weetomin
& Audrey
Oakley
Access
to
cGTACardia
and
Develop
Safety
Healthlinks
Service
Care
OnBase
Framework Care Pathway
LMS System Managing Excellence
Patient
Standard
(IPU)
Portering Service
Med-Surg
Family
P&F Early
Documentation / HBAM/ &
Improve MedQBP
/
DeliveryDepartmental
Clinic
Redesign
Expectations
Involvement
in
Planning
for Long
Surg Clinic
Improve
Cardio
Program
Led
A2C Projects
Senior Friendly
D/C
Planning
Improvements
Weekends
Capacity by
Resp.
TATs
CCAC
Issues
Log:
Hospital
Appropriates
RM&R, CM
Better Utilization
Align Medicine
Management
Work with LHIN
Waiting, CCAC
of Stroke
Internists with
System for
on Rehab / LTC
Policies
Prevention
/
Roles in UMS
Wellsoft /
issues
Clinic
Teletrack Errors
Work on
Weekend Issues
NOW
Access to Care
Project Timeline
Social Worker
Schedule
Daily Goal Rounds
There’s No
Place Like
Home
Med-Surg Clinic
GIM Model
of Care
Physician
Champions
RM&R
Discharge
Management
Planning Event
Sustainability for A2C
Leadership
Walkabouts for
Daily Goal
Rounds
Increase
Private
Rooms
Escalation
Protocol
(Phase 2)
2011/12
2012/13
Patient & Family Early
Involvement in
Discharge Planning
Transportation Service
Improvements
Escalation
Protocol
Short Stay
Beds
ALC Improvements
Escalation Protocol
(Phase 3)
Access to Care
Celebration &
Recognition
Teletracking
Upgrade
Project Planned for
2014-15
2013/14
MI Service
Improvements for ED
2014/15
Escalation Protocol
• Trigger based on
patients waiting in ED,
ICU and elsewhere
• Unassigned are the
patients waiting in ED
that have not been
assigned to a bed
• ED and CTAS
information used to
show volume and
acuity
• Status comes out 5
times a day
What are the Benefits
Patient
transferred to
inpatient unit
Escalation
Protocol:
Transfer patient
waiting to an
unbudgeted bed
immediately
Other patients
waiting benefit
from having
access to care
on inpatient unit
faster
Obtain clinical
services sooner
Better patient outcomes,
safety and patient
experience
Availability of
resources in
Emergency / ICU
Access to Care
Project Timeline
Social Worker
Schedule
Daily Goal Rounds
There’s No
Place Like
Home
Med-Surg Clinic
GIM Model
of Care
Physician
Champions
RM&R
Discharge
Management
Planning Event
Sustainability for A2C
Leadership
Walkabouts for
Daily Goal
Rounds
Increase
Private
Rooms
Escalation
Protocol
(Phase 2)
2011/12
2012/13
Patient & Family Early
Involvement in
Discharge Planning
Transportation Service
Improvements
Escalation
Protocol
Short Stay
Beds
ALC Improvements
Escalation Protocol
(Phase 3)
Access to Care
Celebration &
Recognition
Teletracking
Upgrade
Project Planned for
2014-15
2013/14
MI Service
Improvements for ED
2014/15
Daily Goal Rounds
The Goal: To drive collaboration between members of our multidisciplinary team to
facilitate a safe and effective discharge plan for patients, and their families and caregivers.
Frequency: Every week day before 10:00am for 30-45 minutes
Daily Goal Round Agenda:
• Patient name/Diagnosis/MRP
• Expected Date of Discharge (EDD)
• Daily Goals - i.e., facilitate diagnostic tests,
interventions, clinical assessments, etc.
• Outstanding Issues/Barriers – i.e. any outstanding
items from Diagnostic Imaging, Lab results, referrals,
consults, family meetings, social work,
physiotherapy/occupational therapy, etc.
What’s Different?
• Everyday
• Before 10am
• Frontline nurses
present patients
Daily Goal Rounds
The Goal: to collaborate with the multidisciplinary team to facilitate a safe and
effective discharge plan. At bullet rounds the appropriate traffic light disposition will
be determined.
Allotted Time: 30mins
Agenda:
Be precise
Utilize time well
Look at the big picture
Lean thinking!
Expedite discharges
Team approach
1) Patient name/Diagnosis/MRP
2) EDD (expected discharge date)
3) Daily Goals - i.e. facilitate diagnostic tests,
interventions, clinical assessments etc.
4) Outstanding issues/barriers – i.e. any
outstanding items from Diagnostic Imaging, Lab
results, referrals, consults, family meetings,
social work, PT/OT, etc.
Daily Goal Rounds:
Impact to Staff
“Critical thinking of nurses
has been enhanced, more
proactive. Nurses now come
with a discharge plan and are
asking at Rounds “what the
plan is””
“Students enjoy the
process and participate”
“Nurses are more
accountable and physician
seek out the primary
nurse more than before.”
“Helps to have Unit
Coordinator to delegate
and be more involve as a
coach. It is now off the UC and
more on Nurses”
“More confidence, better
information from nursing,
nurses know their
patients better i.e. lab
results. Lots of great
feedback”
Access to Care
Project Timeline
Social Worker
Schedule
Daily Goal Rounds
There’s No
Place Like
Home
Med-Surg Clinic
GIM Model
of Care
Physician
Champions
RM&R
Discharge
Management
Planning Event
Sustainability for A2C
Leadership
Walkabouts for
Daily Goal
Rounds
Increase
Private
Rooms
Escalation
Protocol
(Phase 2)
2011/12
2012/13
Patient & Family Early
Involvement in
Discharge Planning
Transportation Service
Improvements
Escalation
Protocol
Short Stay
Beds
ALC Improvements
Escalation Protocol
(Phase 3)
Access to Care
Celebration &
Recognition
Teletracking
Upgrade
Project Planned for
2014-15
2013/14
MI Service
Improvements for ED
2014/15
Critical Success Factors
GIM/Physician Model of Care Result:
What is a Specialist in
GENERAL INTERNAL MEDICINE
Geriatrics
Medical School
Cardiology
Infectious
Diseases
Respirology
Internal Medicine
Allergy and
Immunology
Hematology
Gastroenterology
Oncology
Endocrinology
Rheumatology
Specialists in General Internal Medicine or General Internists
Are expert diagnosticians: they are considered medical detectives
Are leaders in medical education, particularly clinical examination
Specialize in the management of patients with multi-system or undifferentiated disease
Sort out illnesses and balance their management
Critical Care Process
(Intensivist - Led Model)
GIM Model of Care
Inpatient Most
Responsible
Physician
Rapid Referral
Clinic
ED
Consultation
Medical
Consult Service
Research Question
• Does the implementation of a general internal medicine
model of care in a community teaching hospital have a
measurable impact on the quality of patient care?
Critical Success Factors
Physician Engagement Score
Staff Engagement Score
85%
66.6%
The provincial 75th
percentile was 66.1%
The provincial 75th percentile
was 66.1%
Culture and Innovation
The Journey Continues
Thank You!

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